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Chen Y, Fogel A, Bi Y, Yen CC. Factors associated with eating rate: a systematic review and narrative synthesis informed by socio-ecological model. Nutr Res Rev 2024; 37:376-395. [PMID: 37749936 DOI: 10.1017/s0954422423000239] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Accumulating evidence shows associations between rapid eating and overweight. Modifying eating rate might be a potential weight management strategy without imposing additional dietary restrictions. A comprehensive understanding of factors associated with eating speed will help with designing effective interventions. The aim of this review was to synthesise the current state of knowledge on the factors associated with eating rate. The socio-ecological model (SEM) was utilised to scaffold the identified factors. A comprehensive literature search of eleven databases was conducted to identify factors associated with eating rate. The 104 studies that met the inclusion criteria were heterogeneous in design and methods of eating rate measurement. We identified thirty-nine factors that were independently linked to eating speed and mapped them onto the individual, social and environmental levels of the SEM. The majority of the reported factors pertained to the individual characteristics (n = 20) including demographics, cognitive/psychological factors and habitual food oral processing behaviours. Social factors (n = 11) included eating companions, social and cultural norms, and family structure. Environmental factors (n = 8) included food texture and presentation, methods of consumption or background sounds. Measures of body weight, food form and characteristics, food oral processing behaviours and gender, age and ethnicity were the most researched and consistent factors associated with eating rate. A number of other novel and underresearched factors emerged, but these require replication and further research. We highlight directions for further research in this space and potential evidence-based candidates for interventions targeting eating rate.
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Affiliation(s)
- Yang Chen
- Division of Industrial Design, National University of Singapore, Singapore
- Keio-NUS CUTE Center, National University of Singapore, Singapore
| | - Anna Fogel
- Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), Singapore
| | - Yue Bi
- Department of Psychology, National University of Singapore, Singapore
| | - Ching Chiuan Yen
- Division of Industrial Design, National University of Singapore, Singapore
- Keio-NUS CUTE Center, National University of Singapore, Singapore
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2
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Gligorić K, Chiolero A, Kıcıman E, White RW, Horvitz E, West R. Food choice mimicry on a large university campus. PNAS NEXUS 2024; 3:pgae517. [PMID: 39677365 PMCID: PMC11645252 DOI: 10.1093/pnasnexus/pgae517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 11/04/2024] [Indexed: 12/17/2024]
Abstract
Social influence is a strong determinant of food consumption, which in turn influences the environment and health. Purchasing mimicry, a phenomenon where a person copies another person's purchases, has been identified as the key governing mechanism. Although consistent observations have been made on the role of purchasing mimicry in driving similarities in food consumption, much less is known about the precise prevalence, the affected subpopulations, and the food types most strongly associated with mimicry effects. Here, we study social influence on food choice through carefully designed causal analyses, leveraging the sequential nature of shop queues on a large university campus. In particular, we consider a large number of adjacent purchases where a focal user immediately follows another user ("partner") in the checkout queue and both make a purchase. Across food additions purchased during lunchtime together with a meal, we find that the focal user is significantly more likely to purchase the food item when the partner buys the item, vs. when the partner does not, increasing the purchasing probability by 14% in absolute terms, or by 83% in relative terms. The effect is observed across all food types, but largest for condiments. Furthermore, purchasing mimicry is present across age, gender, and status subpopulations, but strongest for students and the youngest. We elucidate the behavioral mechanism of purchasing mimicry, and derive direct implications for interventions improving dietary behaviors on campus, such as facilitating preordering to reduce detrimental interactions.
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Affiliation(s)
- Kristina Gligorić
- Computer Science Department, Stanford University, Stanford, CA 94305, USA
| | - Arnaud Chiolero
- Population Health Laboratory (#PopHealthLab), University of Fribourg, 1700 Fribourg, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, 3012 Bern, Switzerland
- School of Population and Global Health, McGill University, Montreal, Quebec H3A 0G4, Canada
| | | | | | | | - Robert West
- School of Computer and Communication Sciences, EPFL, 1015 Lausanne, Switzerland
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3
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Ash PA, Benzaquén E, Gander PE, Berger JI, Kumar S. Mimicry in misophonia: A large-scale survey of prevalence and relationship with trigger sounds. J Clin Psychol 2024; 80:186-197. [PMID: 37850971 DOI: 10.1002/jclp.23605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 09/07/2023] [Accepted: 09/30/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Misophonia is often referred to as a disorder that is characterized by excessive negative emotional responses, including anger and anxiety, to "trigger sounds" which are typically day-to-day sounds, such as those generated from people eating, chewing, and breathing. Misophonia (literally "hatred of sounds") has commonly been understood within an auditory processing framework where sounds cause distress due to aberrant processing in the auditory and emotional systems of the brain. However, a recent proposal suggests that it is the perceived action (e.g., mouth movement in eating/chewing sounds as triggers) of the trigger person, and not the sounds per se, that drives the distress in misophonia. Since observation or listening to sounds of actions of others are known to prompt mimicry in perceivers, we hypothesized that mimicking the action of the trigger person may be prevalent in misophonia. Apart from a few case studies and anecdotal information, a relation between mimicking and misophonia has not been systematically evaluated. METHOD In this work, we addressed this limitation by collecting data on misophonia symptoms and mimicry behavior using online questionnaires from 676 participants. RESULTS Analysis of these data shows that (i) more than 45% of individuals with misophonia reported mimicry, indicating its wide prevalence, (ii) the tendency to mimic varies in direct proportion to misophonia severity, (iii) compared to other human and environmental sounds, trigger sounds of eating and chewing are more likely to trigger mimicking, and (iv) the act of mimicking provides some degree of relief from distress to people with misophonia. CONCLUSION This study shows prevalence of mimicry and its relation to misophonia severity and trigger types. The theoretical framework of misophonia needs to incorporate the phenomenon of mimicry and its effect on management of misophonia distress.
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Affiliation(s)
- Paris A Ash
- School of Psychology, University of Sunderland, Sunderland, UK
| | - Ester Benzaquén
- Newcastle University Medical School, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Phillip E Gander
- Department of Radiology, University of Iowa, Iowa City, Iowa, USA
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa, USA
| | - Joel I Berger
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa, USA
| | - Sukhbinder Kumar
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa, USA
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Wang JY, Kubota S, Inoue T. Effects of Meal Similarity on Interpersonal Synchronization in Three-Party Remote Dining. FRONTIERS IN COMPUTER SCIENCE 2022. [DOI: 10.3389/fcomp.2022.838229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In recent years, online commensality, such as remote dining, has become a way to connect people in different places. In remote dining, people have drinks, snacks, or meals while chatting with each other via video calls and seek connectedness and belonging. However, many people feel that there is a gap between real-life and digital co-eating and that interaction in current remote dining fails to satisfy the need for companionship. Unlike real-life co-eating, in remote dining, one's meal may not be similar to that of a partner's because people usually prepare their own food separately. In this study, we focused on the effects of meal similarity on interpersonal synchronization and subjective feelings. We conducted a laboratory-based remote dining experiment and video analysis to investigate whether eating similar meals in remote conditions has any effect on eating behavior and to explore the relationship between meal similarity, interpersonal synchronization, and subjective feelings. The results showed that participants ate at a faster pace and conducted eating actions more frequently. They were more synchronized with their partners, and the feeling of togetherness was stronger. Thus, we suggest that preparing similar meals or ordering the same dishes can enhance the remote dining experience.
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Taylor JC, Allman-Farinelli M, Chen J, Gauglitz JM, Hamideh D, Jankowska MM, Johnson AJ, Rangan A, Spruijt-Metz D, Yang JA, Hekler E. Perspective: A Framework for Addressing Dynamic Food Consumption Processes. Adv Nutr 2022; 13:992-1008. [PMID: 34999744 PMCID: PMC9340970 DOI: 10.1093/advances/nmab156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/12/2021] [Indexed: 11/22/2022] Open
Abstract
The study of food consumption, diet, and related concepts is motivated by diverse goals, including understanding why food consumption impacts our health, and why we eat the foods we do. These varied motivations can make it challenging to define and measure consumption, as it can be specified across nearly infinite dimensions-from micronutrients to carbon footprint to food preparation. This challenge is amplified by the dynamic nature of food consumption processes, with the underlying phenomena of interest often based on the nature of repeated interactions with food occurring over time. This complexity underscores a need to not only improve how we measure food consumption but is also a call to support theoreticians in better specifying what, how, and why food consumption occurs as part of processes, as a prerequisite step to rigorous measurement. The purpose of this Perspective article is to offer a framework, the consumption process framework, as a tool that researchers in a theoretician role can use to support these more robust definitions of consumption processes. In doing so, the framework invites theoreticians to be a bridge between practitioners who wish to measure various aspects of food consumption and methodologists who can develop measurement protocols and technologies that can support measurement when consumption processes are clearly defined. In the paper we justify the need for such a framework, introduce the consumption process framework, illustrate the framework via a use case, and discuss existing technologies that enable the use of this framework and, by extension, more rigorous study of consumption. This consumption process framework demonstrates how theoreticians could fundamentally shift how food consumption is defined and measured towards more rigorous study of what, how, and why food is eaten as part of dynamic processes and a deeper understanding of linkages between behavior, food, and health.
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Affiliation(s)
| | | | - Juliana Chen
- Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Julia M Gauglitz
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California, San Diego, San Diego, CA, USA
| | - Dina Hamideh
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California, San Diego, San Diego, CA, USA
| | - Marta M Jankowska
- Department of Population Sciences, Beckman Research Institute of City of Hope, Duarte, CA, USA
| | - Abigail J Johnson
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Anna Rangan
- Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Donna Spruijt-Metz
- Center for Economic and Social Research, University of Southern California, Los Angeles, CA, USA
| | - Jiue-An Yang
- Department of Population Sciences, Beckman Research Institute of City of Hope, Duarte, CA, USA
| | - Eric Hekler
- The Design Lab, University of California, San Diego, San Diego, CA, USA,Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, San Diego, CA, USA
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Kumar S, Dheerendra P, Erfanian M, Benzaquén E, Sedley W, Gander PE, Lad M, Bamiou DE, Griffiths TD. The Motor Basis for Misophonia. J Neurosci 2021; 41:5762-5770. [PMID: 34021042 PMCID: PMC8244967 DOI: 10.1523/jneurosci.0261-21.2021] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/20/2021] [Accepted: 04/27/2021] [Indexed: 12/01/2022] Open
Abstract
Misophonia is a common disorder characterized by the experience of strong negative emotions of anger and anxiety in response to certain everyday sounds, such as those generated by other people eating, drinking, and breathing. The commonplace nature of these "trigger" sounds makes misophonia a devastating disorder for sufferers and their families. How such innocuous sounds trigger this response is unknown. Since most trigger sounds are generated by orofacial movements (e.g., chewing) in others, we hypothesized that the mirror neuron system related to orofacial movements could underlie misophonia. We analyzed resting state fMRI (rs-fMRI) connectivity (N = 33, 16 females) and sound-evoked fMRI responses (N = 42, 29 females) in misophonia sufferers and controls. We demonstrate that, compared with controls, the misophonia group show no difference in auditory cortex responses to trigger sounds, but do show: (1) stronger rs-fMRI connectivity between both auditory and visual cortex and the ventral premotor cortex responsible for orofacial movements; (2) stronger functional connectivity between the auditory cortex and orofacial motor area during sound perception in general; and (3) stronger activation of the orofacial motor area, specifically, in response to trigger sounds. Our results support a model of misophonia based on "hyper-mirroring" of the orofacial actions of others with sounds being the "medium" via which action of others is excessively mirrored. Misophonia is therefore not an abreaction to sounds, per se, but a manifestation of activity in parts of the motor system involved in producing those sounds. This new framework to understand misophonia can explain behavioral and emotional responses and has important consequences for devising effective therapies.SIGNIFICANCE STATEMENT Conventionally, misophonia, literally "hatred of sounds" has been considered as a disorder of sound emotion processing, in which "simple" eating and chewing sounds produced by others cause negative emotional responses. Our data provide an alternative but complementary perspective on misophonia that emphasizes the action of the trigger-person rather than the sounds which are a byproduct of that action. Sounds, in this new perspective, are only a "medium" via which action of the triggering-person is mirrored onto the listener. This change in perspective has important consequences for devising therapies and treatment methods for misophonia. It suggests that, instead of focusing on sounds, which many existing therapies do, effective therapies should target the brain representation of movement.
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Affiliation(s)
- Sukhbinder Kumar
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, United Kingdom
| | - Pradeep Dheerendra
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, United Kingdom
| | - Mercede Erfanian
- UCL Institute for Environmental Design and Engineering, The Bartlett, University College London, WC1H 0NN, United Kingdom
| | - Ester Benzaquén
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, United Kingdom
| | - William Sedley
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH
| | - Phillip E Gander
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa 52242
| | - Meher Lad
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH
| | - Doris E Bamiou
- UCL Ear Institute, London, WC1X 8EE, United Kingdom
- Biomedical Research Centre, University College London Hospitals, London, WC1E 6AB, United Kingdom
| | - Timothy D Griffiths
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, NE2 4HH, United Kingdom
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa 52242
- Wellcome Centre for Human NeuroImaging, London, WC1N 3BG, United Kingdom
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7
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Koehly LM, Persky S, Philip Shaw, Bonham VL, Marcum CS, Sudre GP, Lea DE, Davis SK. Social and behavioral science at the forefront of genomics: Discovery, translation, and health equity. Soc Sci Med 2021; 271:112450. [PMID: 31558303 PMCID: PMC9745643 DOI: 10.1016/j.socscimed.2019.112450] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 07/25/2019] [Indexed: 12/15/2022]
Abstract
This special issue highlights the unique role that social and behavioral science has to play at the forefront of genomics. Through the introduction of papers comprising this special issue, we outline priority research areas at the nexus of genomics and the social and behavioral sciences. These include: Discovery science; clinical and community translation, and equity, including engagement and inclusion of diverse populations in genomic science. We advocate for genomic discovery that considers social context, neural, cognitive, and behavioral endophenotypes, and that is grounded in social and behavioral science research and theory. Further, the social and behavioral sciences should play a leadership role in identifying best practices for effective clinical and community translation of genomic discoveries. Finally, inclusive research that engages diverse populations is necessary for genomic discovery and translation to benefit all. We also highlight ways that genomics can be a fruitful testbed for the development and refinement of social and behavioral science theory. Indeed, an expanded ecological lens that runs from genomes to society will be required to fully understand human behavior.
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Affiliation(s)
- Laura M Koehly
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Susan Persky
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Philip Shaw
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Vence L Bonham
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Christopher S Marcum
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Gustavo P Sudre
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Dawn E Lea
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Sharon K Davis
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
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8
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Bell BM, Alam R, Alshurafa N, Thomaz E, Mondol AS, de la Haye K, Stankovic JA, Lach J, Spruijt-Metz D. Automatic, wearable-based, in-field eating detection approaches for public health research: a scoping review. NPJ Digit Med 2020; 3:38. [PMID: 32195373 PMCID: PMC7069988 DOI: 10.1038/s41746-020-0246-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 02/13/2020] [Indexed: 11/09/2022] Open
Abstract
Dietary intake, eating behaviors, and context are important in chronic disease development, yet our ability to accurately assess these in research settings can be limited by biased traditional self-reporting tools. Objective measurement tools, specifically, wearable sensors, present the opportunity to minimize the major limitations of self-reported eating measures by generating supplementary sensor data that can improve the validity of self-report data in naturalistic settings. This scoping review summarizes the current use of wearable devices/sensors that automatically detect eating-related activity in naturalistic research settings. Five databases were searched in December 2019, and 618 records were retrieved from the literature search. This scoping review included N = 40 studies (from 33 articles) that reported on one or more wearable sensors used to automatically detect eating activity in the field. The majority of studies (N = 26, 65%) used multi-sensor systems (incorporating > 1 wearable sensors), and accelerometers were the most commonly utilized sensor (N = 25, 62.5%). All studies (N = 40, 100.0%) used either self-report or objective ground-truth methods to validate the inferred eating activity detected by the sensor(s). The most frequently reported evaluation metrics were Accuracy (N = 12) and F1-score (N = 10). This scoping review highlights the current state of wearable sensors' ability to improve upon traditional eating assessment methods by passively detecting eating activity in naturalistic settings, over long periods of time, and with minimal user interaction. A key challenge in this field, wide variation in eating outcome measures and evaluation metrics, demonstrates the need for the development of a standardized form of comparability among sensors/multi-sensor systems and multidisciplinary collaboration.
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Affiliation(s)
- Brooke M. Bell
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089 USA
| | - Ridwan Alam
- Department of Electrical and Computer Engineering, School of Engineering and Applied Science, University of Virginia, Charlottesville, VA 22904 USA
| | - Nabil Alshurafa
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611 USA
- Department of Computer Science, McCormick School of Engineering, Northwestern University, Chicago, IL 60611 USA
| | - Edison Thomaz
- Department of Electrical and Computer Engineering, Cockrell School of Engineering, The University of Texas at Austin, Austin, TX 78712 USA
| | - Abu S. Mondol
- Department of Computer Science, School of Engineering and Applied Science, University of Virginia, Charlottesville, VA 22904 USA
| | - Kayla de la Haye
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089 USA
| | - John A. Stankovic
- Department of Computer Science, School of Engineering and Applied Science, University of Virginia, Charlottesville, VA 22904 USA
| | - John Lach
- Department of Electrical and Computer Engineering, School of Engineering and Applied Science, The George Washington University, Washington, DC 20052 USA
| | - Donna Spruijt-Metz
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089 USA
- Center for Economic and Social Research, Dornsife College of Letters, Arts, and Sciences, University of Southern California, Los Angeles, CA 90089 USA
- Department of Psychology, Dornsife College of Letters, Arts, and Sciences, University of Southern California, Los Angeles, CA 90089 USA
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Wu YP, Herbert LJ, Walker-Harding LR, Tercyak KP. Introduction to the special issue on child and family health: the role of behavioral medicine in understanding and optimizing child health. Transl Behav Med 2019; 9:399-403. [PMID: 31094430 PMCID: PMC6520805 DOI: 10.1093/tbm/ibz056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Health promotion during early life and childhood can reduce the prevalence and impact of acute and chronic health conditions later in life. Research regarding factors that influence child and family health, prevention, and intervention programs that address them, and policies that promote implementation of best practices are needed to efficiently and effectively address the multi-faceted, biopsychosocial influences on child health, especially among youth from underserved backgrounds. The current special issue dedicated to child and family health offers a series of articles that illustrate how explanatory studies and targeted intervention programs for children, families, health care providers, and communities can be used to improve child health. Articles in this special issue are organized into three areas related to child and family health: (i) diet and nutrition, (ii) cancer prevention and control, and (iii) social determinants of health and health care. The articles included in this special issue underscore that behavioral medicine practitioners, researchers, and policy makers are well poised to lead innovative efforts to promote child health across clinical, community, health care, and population settings.
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Affiliation(s)
- Yelena P Wu
- Cancer Control and Population Sciences, Huntsman Cancer Institute, Salt Lake City, UT, USA
- Department of Dermatology, University of Utah, Salt Lake City, UT, USA
| | - Linda J Herbert
- Division of Psychology and Behavioral Health, Children’s National Medical Center, Washington, DC, USA
- Department of Pediatrics, George Washington University School of Medicine, Washington, DC, USA
| | - Leslie R Walker-Harding
- Department of Pediatrics, University of Washington and Seattle Children’s Hospital, Seattle, WA, USA
| | - Kenneth P Tercyak
- Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, USA
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